Injuries and their Prevention in Racquetball

Unfortunately, racquetball is not a well-researched sport in comparison to other racquet sports such as tennis or table tennis. Much of the data available regarding calories burned during a game, for example, come from data acquired in the 1980s and 1990s when equipment and gameplay was very different.

However, we were delighted to learn of a racquetball study that was recently completed by Mexican LPRT racquetball player and university student Carolina Rivera Luque. Her thesis, as part of her physical therapy degree, was about racquetball injuries. Therefore, we asked her to share a little about what she found.

Why were you interested in studying racquetball athletes for your thesis?

I became interested in racquetball injuries because of my own experiences. I was a junior champion of the 16U division of the Mexican National Olympics, but I suffered a serious injury. I tore my meniscus not long after obtaining the title, but before the national qualifier for the Junior World Championships.

I got injured during preseason training, but I was not the only one who was injured; I saw several other players get injured before, during, and after tournaments. I began to wonder whether there was something wrong with how racquetball players were training for tournaments. I also questioned whether playing so many matches in such a short period of time also affected injury rates. I was not sure if it was due to the biomechanics of the swing or something else.

I did some research on racquetball injuries and found very little information. I found articles describing ocular (eye) injuries but not much else. However, I knew from researching other sports such as soccer that the prevalence and incidence of injuries depends on position, the number of hours of practice and games per week, weaknesses in the muscles, and other things. But there was no data or information on the injuries that occur in racquetball.

Who did you study? Tell us a little bit about your methodology.

I actually started my investigation in 2016 and interviewed athletes that had experienced injuries. I chose racquetball athletes in the 16 and under division (born in 1999 or 2000). I chose this group because I had noted that it is at about this age where players start having pain or injuries that affect their training. At this age, athletes are training much harder and play more tournaments per year. This age group is part of the Pan-American Games, Junior World Championships, and National Championships. They also compete in a variety of other open tournaments around the country.

The book Total Training for Junior Champions by Tudor Bompa presents training guidelines and goals oriented to specific age groups and sports. It also considering gender differences along puberty. He emphasizes the importance of tailoring programs to maturational levels instead of chronological ages. Bompa addresses all phases of development, including prepuberty—the period of initiation; puberty—the phase of athletic formation; and post puberty—the time of specialization. He mentions maturation, which is associated with elite athletic phase.

One of the main problems with injuries in adolescents is that early specialization violates the mutilaterality principle (which is the first phase, development phase in which the child should be able to develop skill proficiency across multiple areas: balance and agility while rolling, throwing, kicking, catching, ducking, jumping, crawling, dribbling, etcetera).

During the athletic formation phase, which takes place from 12-16, girls find themselves in an extreme hormonal experience, and many studies have noted an association between capsular and ligament distention during the premenstrual phase of the cycle. This requires restructuring training programs, especially mesocycles that can be adapted to the progesterone and estrogen phases of the menstrual cycle. For instance, trainers should consider implementing more coordinative skills training, technique, stretching, and proprioception during their PMS instead of a power training program that may injure ligaments or muscles; laxity increases significantly throughout the menstrual cycle when comparing baseline with peak levels of estrogen and progesterone.

Other injuries at this age may be associated with growth development. Such an example is Osgood Schlatter’s disease, which is a painful, bony growth that occurs on the shinbone just below the knee often during puberty. This is also a very prevalent disorder in youth that train in high impact sports (e.g., basketball, volleyball, soccer, jumping, running) along with early maturation of bone epiphysis because of the over stimulation and load on the femur, tibia, humerus, radius, etc. Many authors agree that youth under 15 are still developing basic skills and skipping this psychomotricity step can generate dysfunctions and complications or even “burn out” the athlete when trying to develop a more complex skill such as a racquetball swing. In other words, this is an age where young athletes are training more, competing more, but are still developing their physical and mental skills.

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What did you discover?

The injury history said that most righties have more injuries on their right side and the lefties have more injuries on their left side. This suggests the dominance of a cross chain overuse or may be an imbalance in the muscle length-strength relationship (this is one of the things I would like to study specifically) during the swing of the righties during their forehand motion (weight transfer to the left leg, torsion of the hips, thorax and scapular waist/shoulder twist). In the case of lefties, the over use of the arm, elbow, and wrist points to be the most important issue and their sustentation base during the swing seemed to be the main problem related to their leg. In the righties, the issues were with their left knee, ankle and thigh, but the upper body (arms, elbow, wrist, hand) injuries in the righties took place on the right side.

Those who were left-handed (7 athletes) experienced more injuries on their left side and reported more pain in general on that side. It is my hypothesis that left-handed players are over using their lower left limb (legs) to execute their back hand. In comparison, I discovered that right handed players put too much demand on their legs during serves and forehands which cause lower extremity injuries such as knee pain during and after competition, muscle tears, and ankle sprains. I also found that those with ankle sprains experienced a repetitive incidence of the injury; once they experienced a sprain, they often sprained it more than once. This suggests that rehabilitation and strengthening of the injured joint is not taking place and should be implemented as a preventative procedure.

Seven surgeries were reported, but only four were muscle skeletal and significantly impacted their training. All were treated with physical therapy. The only surgery related indirectly to racquetball was the knee surgery due to gonarthrosis (chondromalacia patellae). Interestingly, only 7 out of the 72 non-surgical injuries were treated with physical therapy. Our culture has not taught most of the community the algorithm of re-integration to sports after an injury. Here is where I would like to intervene with an active rest protocol and a more specific physical therapy intervention that will lead to a functional recovery, reinforcement, and probable adjustments of the technical aspects of the basic skills on their everyday activities and specific racquetball movements.

Do you think there are more or less injuries in racquetball than other similar sports like tennis?

As part of my study, I researched other racquet sports such as badminton, table tennis, and squash. There were reports of injuries in the lower back, shoulder impingement, and knees. This data coincides with the finding of my study. There were also several reports on pathologies specific to a sport such as golfer's elbow. I did an evaluation of injuries in table tennis and found that the Cuban national team reported more injuries in the upper limbs. This might be expected because table tennis does not require as much movement across space compared to racquetball.

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As an athlete, what could I do to help prevent some of the injuries that you reported?

For those competing, I strongly recommend having annual sports medicine or physical therapy evaluations. Having coaching or a certified trainer to help athletes in this area is also highly recommended. In my opinion, no matter the sport, everyone should begin activity with a complete warm up. This should include a focus on strength, balance, core activation, and flexibility before practicing. Athletes should complete functional movement that uses correct form. For that you need core stability and strength. 

There must be a balance between flexibility and strength of the main muscle groups, and I recommend dedicating at least two sessions a week for flexibility training. Flexibility training should not be done on the same day as strength training.

When strength training, train isolated muscles with negative phases. In other words, control how you return the muscle to its relaxed phase. Too many people make a big effort during the concentric movement (e.g., jumping) but pay no attention to the eccentric movement (e.g., landing) which is statistically the main mechanism of injuries and the instability in this phase along with the muscle weakness-tightness relationship (agonist shortening subsequently generates unhealthy elongations in the antagonist groups and therefore a compensation because of the body’s tensegrity model). 

What do you want to explore next?

I would like to do a study investigating the injuries of professional players and compare them to other sports and other levels. I would also like to evaluate pain zones during practice or competition and compare it to an athlete’s hours of training and the number of tournaments in which they compete.

Eventually, I would like to develop injury prevention programs and rehabilitation protocols that are racquetball specific. I would like to investigate the impact of the vibrations in the tendons, core and scapular stability, and eventually use biomechanical analysis to aid in the development of safe and effective fundamental swing and movement pattern technique in racquetball. I would like to promote health and sports in my community, organize talks for patient education and forums where we can dialogue about what can be improved in our performance and training without risking the health of the athletes.

I am planning to assist at the Junior World Championships this year and my hope is that the National Federation will allow me to interview and assess these junior athletes to continue building on the data that I already have. Doing so will allow me to continue targeting areas for improvement in the sport when it comes to injury prevention and rehabilitation.